Iron-deficiency anaemia is one of the main nutritional
problems in Indonesia, with a prevalence of 63.5% in pregnant
women and 55.5% in pre-school children. Its frequency is related
to low iron and folic acid contents of the diet. Intervention
programmes to alleviate irondeficiency anaemia are iron tablets
for adults, iron syrup for infants and schoolchildren, and iron
fortification of foods. Our studies have demonstrated that iron
supplementation can reduce the prevalence of anaemia in pregnant
women by 20% to 25%, and iron fortification can reduce it by 20%
for those consuming the fortified foods. If iron-supplementation,
iron-fortification, and diet-modification programmes were fully
implemented in a community, the expected reduction in the
prevalence of anaemia would be greater.

Introduction

Iron-deficiency anaemia is one of the main nutritional
problems in Indonesia because of its devastating consequences and
its magnitude. It is widespread not only in pregnant women but
also among children under five years of age, schoolchildren, and
low-income workers. Many studies have been conducted in Indonesia
to assess the prevalence and the cause of anaemia and to evaluate
various methods of solving the problem. As a result, considerable
knowledge has been accumulated; however, despite many successful
interventions in study settings, the prevalence of anaemia,
especially in pregnant women, remains high. This raises many
questions about the effectiveness of interventions in the
community setting, including the question of compliance in
consuming the recommended doses.

The prevalence of anaemia in Indonesia

Table 1 presents the prevalence of anaemia among pregnant
women in various parts of Indonesia and its prevalence at the
national level. These data show that the prevalence in various
parts of the country ranges between 38.0% and 71.5%, and the
average prevalence for all of Indonesia is about 63.5%.
Surprisingly, Java, the most developed part of Indonesia, is
among the areas with the highest prevalence- 57.8% to 71.5%.
Irian Jaya, one of the less developed areas, has the lowest
prevalence (38%).

The prevalence of anaemia in pre-school children in various
parts of Indonesia is between 35.8% and 60.6%, and the average
prevalence at the national level is 55.5% (table 2). Similar to
the situation in pregnant women, the lowest prevalence in
preschool children is in Irian Jaya (35.8%). In central Java the
prevalence in schoolchildren (44.9%) is among the lowest, whereas
that in pregnant women (62.5%) is among the highest.

Causes of anaemia in Indonesia

In the early 1970s, analysis of blood from pregnant women
found that the transferrin saturation was less than 16%,
indicating that anaemia was caused by iron deficiency [4].
Although the vitamin B12 status of these women was normal, their
folic acid status was marginal. Therefore, in addition to iron
deficiency, it seemed that folate deficiency might be
contributing to the problem of anaemia. Eighteen years later,
more evidence was provided that anaemia was caused by iron
deficiency with the finding that ferritin values of anaemic
pregnant women were low and free erythrocyte protoporphyrin (FEP)
(also known as zinc protophorphyrin) values were high [5].

The source and bioavailability of iron are influenced by the
composition of the diet. In the early 1970s, a series of studies
[4, 6] on the prevalence of anaemia among pregnant women was
conducted in areas where the staple foods were rice, sweet
potatoes, and cassava. There was a tendency toward a higher
prevalence of anaemia among pregnant women in areas where the
proportion of rice in the diet was higher (table 3). Among women
in an area where rice was the only staple food, 77% suffered from
anaemia, compared with only 46% in an area where cassava was the
dominant staple food. Unfortunately, no information is available
on the causes of the differences in the prevalence among areas
with different staple foods. However, three questions arise: 1.
Does rice contain more substances that inhibit the absorption of
iron than other staple foods?

2. Do people in rice-eating areas have more hookworm
infestation because of a greater number of worms in the
environment and/or more exposure to worms from direct contact
with mud, especially during land preparation and planting?

3. Do people in areas in which rice is not the only staple
food consume more pulses or other foods rich in iron?

Hookworm infestations are another major cause of iron
deficiency [4], and therefore any intervention to combat anaemia
in Indonesia should include deworming.

TABLE 1. Prevalence of anaemia in pregnant women

Province

No. of subjects

Prevalence (%)

Ref.

West Java

221

71.5

1

Central Java

224

62.5

1

East Java

176

57.8

1

North Sulawesi

115

48.7

1

Southeast Sulawesi

867

67.4

2

East Nusa Tenggara

441

51.0

3

East Timor

382

64.7

3

Maluku

457

48.4

3

Irian Jaya

426

38.0

3

National

63.5

1

TABLE 2. Prevalence of anaemia in pre-school children

Province

No. of subjects

Prevalence (%)

Ref.

Central Java

224

44.9

1

West Nusa Tenggara

167

51.9

1

East Nusa Tenggara

493

48.9

3

East Timor

444

60.6

3

Maluku

443

48.8

3

Irian Jaya

399

35.8

3

National

55.5

1

TABLE 3. Prevalence of anaemia in pregnant women in areas with
different staple foods

Area

Staple foods

Prevalence (%)

Indramayu + Purwakarta (west
Java)

Rice

77

Bali

Rice + sweet potato

56

Gunung Kidul (Yogyakarta)

Cassava + rice

46

Bogor (west Java)

Rice

57

Source: Ref.4.

Intervention studies

An increase in hemoglobin and a decrease in the prevalence of
anaemia have been consistently reported from daily iron
supplementation studies. Table 4 shows the results summarized in
a 1985 report for supplements provided by health workers or by
teachers in the case of schoolchildren. Table 5 shows the results
for other studies in which the distribution of iron supplements
was supervised. It should be noted that compliance was
particularly variable in the case of pregnant women, many of whom
did not take the supplement because of side effects such as
dizziness and nausea. Another reason for poor compliance was
concern for the darkening of their faeces.

TABLE 4. Effect of iron supplements distributed by health
workers or schoolteachers on haemoglobin (Hb) levels and
prevalence of anaemia

Evaluations of the coverage of iron distribution among
pregnant women were conducted in various areas in Indonesia [2,
14]. Coverage ranged from 30.8% to 78.6% (table 6).
Unfortunately, these studies did not provide information on
compliance. However, judging from the high prevalence of anaemia
among pregnant women, one can conclude that despite moderate
coverage, compliance was very low.

How to reduce the prevalence of anaemia among pregnant
women

Three approaches have been considered for reducing the
prevalence of anaemia: supplementation, fortification, and diet
modification. Supervised supplementation with iron tablets was
able to reduce the prevalence of anaemia by an average of 24%.
Converting this reduction into the community-based programme
setting, the reduction due to iron supplementation will depend on
the degree of compliance achieved with a weekly dose that is
essentially free of side effects. In our studies this reduction
was 20% to 25%.

TABLE 6. Coverage of iron tablet distribution

District

% coverage

Tanggerang

70.9

Serang

61.8

Pinrang

70.8

Soppeng

78.6

Kendari

54.6

Kolaka

46.7

Buton

46.5

Muna

30.8

Source: Refs. 2 and 14.

The reduction of the prevalence of anaemia by adding 10 mg of
elemental iron was approximately 20% [15] when the fortified
foods were consumed. Since not all pregnant women will be
consuming the fortified foods, the actual reduction will be
somewhat less.

There are no solid data on the impact of diet modification.
The best estimate for reducing anaemia by this method, about 10%,
is obtained by comparing the prevalence of anaemia in an area
with deficient staple food to that in areas with other staple
foods. Diet modification requires a long time to be implemented.

The most desirable outcome would be the concurrent
implementation of all three approaches.

References

1. Institute for Health Research and Development and Central
Bureau of Statistics. National household health survey. Bogor:
Institute for Health Research and Development, 1992.

2. Nutrition Research and Development Centre and Directorate
of Community Nutrition. Study on the assessment of nutritional
anaemia. Bogor: Nutrition Research and Development Centre, 1993.

3. Nutrition Research and Development Centre and Directorate
of Nutrition. Eastern island nutrition status prevalence study.
In-country report. Bogor: Nutrition Research and Development
Centre, 1991.

13. Rustam E. Development of iron pills delivery system
through traditional birth attendants and village midwives.
Project report. Bogor: Nutrition Research and Development Centre,
1994.

14. Department of Health, Provincial Office of South-East
Sulawesi and Nutrition Research and Development Centre. Study of
anemia in pregnant women and underfives for planning program for
combating anemia in the second step of long term development.
Bogor: Nutrition Research and Development Centre, 1994.